Autism and Tricare

A class action suit was filed in U.S. District Court on behalf of military retirees who have children with autism, alleging that TRICARE did not provide coverage for applied behavior analysis (ABA) therapy under the medical benefit. Previously, the TRICARE program only provided coverage for ABA therapy under the TRICARE Extended Care Health Option (ECHO) program for active duty military family members. The judge sent the class-action suit back to TRICARE with instructions to provide coverage for ABA therapy for all beneficiaries who otherwise qualify for reimbursement. As a result of the court order, TRICARE Management Activity (TMA) will cover ABA therapy under the TRICARE medical benefit for all eligible beneficiaries in accordance with applicable requirements that ensure the need and quality of the care.

Although an interim policy is in place, covering ABA therapy under the TRICARE medical benefit is extremely complex and further guidance is forthcoming. The coverage is retroactive to February 16, 2010 in the United States and February 16, 2008 overseas, in accordance with TRICARE filing deadlines and policy. The implementation of ABA therapy under the TRICARE medical benefit is separate from the Autism services or the Enhanced Access to Autism Services Demonstration available to Active Duty family members enrolled in the ECHO program. ABA services under the TRICARE medical benefit will require a specific autism spectrum disorder (ASD) diagnosis rendered by a TRICARE authorized primary care provider or specialized ASD provider, as follows: Primary Care Manager (PCM) under the TRICARE Prime or TRICARE Prime Remote for Active Duty Family Member (TPRADFM) programs; TRICARE-authorized family practice, general medicine, internal medicine, and pediatric physicians under the TRICARE Standard program; or Military Treatment Facility (MTF) provider or team of providers or a network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. Physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or child psychiatry; or Ph.D. clinical psychologist working primarily with children.

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